Lorien Nursing & Rehab Ctr - Elkridge

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and interview, it was determined that the facility failed to maintain a medical record in the most accurate form. The was found to be evident for 1 (Resident #33) of 35 residents reviewed during the investigation phase of the survey.The findings include:MOLST (Medical Orders for Life-Sustaining Treatment) is a medical order form that translates a patient's preferences for end-of-life care into actionable instructions for healthcare providers. Unlike a living will or healthcare proxy, which are legal documents for future use, a MOLST form consists of actual medical orders that must be followed immediately by all health professionals, including emergency medical services (EMS).A hard chart (or paper chart) is the physical, tangible medical record for a resident. Resident #33's electronic medical record (EHR) was reviewed on [DATE] at 1:54 PM. Resident #33 had an active order that was placed on [DATE] that read, NO CPR (Cardiopulmonary Resuscitation) OPTION A-2, DO NOT…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on administrative record review and staff interview, it was determined that the facility failed to ensure staff received training on abuse, neglect, and exploitation training. This deficient practice was evident for 1 of 5 employee files reviewed during the annual survey.The findings include:On 02/10/2026 at 10:45 AM, a review of Geriatric Nursing Assistant (GNA) #16s employee file revealed a hired date of October 2025. Further review failed to show evidence of abuse training.During an interview with the Director of Nursing (DON) on 02/10/2026, she explained that newly hired GNA's complete two days in office orientation, followed by two to three days of training on nursing unit. The surveyor informed the DON that education was missing from GNA #16s employee file and request to review the training files.On 02/10/2026 at 2:43 PM, the DON informed the surveyor that the facility failed to maintain documentation of abuse training for GNA #16.On 02/11/2026 the Administrator was made aware of the finding.

Based on administrative record review and staff interview, it was determined that the facility failed to ensure staff received required compliance and ethics training. This deficient practice was evident for 3 of 5 employee files reviewed during the annual survey.The findings include:On 02/10/2026 at 10:45 AM, a review of Geriatric Nursing Assistant (GNA) #17's employee file revealed a hired date of March 2024. Further review of the file failed to show evidence of compliance and ethics training completed in 2025. The surveyor reviewed four additional employees files and identified that compliance and ethics training was missing for GNA # 14 and GNA #16.During an interview with the Director of Nursing (DON) on 02/10/2026, the surveyor informed the DON that documentation of 2025 compliance and ethics training was missing from three GNA employee files. The surveyor again requested evidence of completed compliance and ethics training for the three GNAs. On 02/10/2026 at 2:43 PM, the DON informed the surveyor that the facility failed to maintain documentation of compliance and ethics…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review and interview, the facility staff failed to thoroughly investigate a complaint of missing personal items (Resident #6). This was evident for 1 out of 12 residents reviewed during a complaint survey. Findings include: Review of resident #6's complaint (MD 00214419) on 4/25/25 at 11:52 am revealed the resident's family made an allegation that the resident's personal items (an adult puzzle and a electronic sound amplifier device) are missing. The surveyor reviewed the resident #6's medical record on 4/25/25 at 12:05pm. The review revealed the resident's records had no evidence of an inventory sheet that listed the puzzle or electronic sound amplifer device. Interview with the Director of Nursing (DON) on 4/25/25 at 1:00pm revealed a grievance/complaint that the complainant reported that a search of the resident #6's room revealed several missing personal items: a puzzle and a electronic sound amplifier device. The surveyor stated that there was no evidence that the facility investigated the complaint. The DON confirmed that the investigation was not done…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review and interview, the facility failed to accurately document medical information in a resident's medical record (Resident #7). This was evident for 1 out of 12 residents reviewed during a compliant survey. The findings include: Review of complaint MD00214151 on 4/25/25 at 3:00pm revealed resident #7's family complained that the facility failed to provide ADL care for the resident during his/her stay causing the resident to develop a preventable wound. Review of resident #7's medical records on 4/25/25 at 3:15pm revealed the facility nursing staff failed to document ADL care on 1/15/25 (day shift), 1/20/25 (evening shift) and 1/23/25 (night shift). During an interview with the Director of Nursing (DON) on 4/25/25 at 3:40pm, the DON confirmed that facility nursing staff failed to document ADL care for resident #7 on 1/15/25, 1/20/25, and 1/23/25.

Based on record review, and interviews, it was determined that the facility failed to provide a Resident's Representative/guardian the right to be involved in the initial care planning process. This was found evident in 1 (Resident #162) of 5 residents reviewed for rights. The finding include: On 9/12/24 at 6:36 AM, the surveyor reviewed Resident #162's medical record. The review revealed that Resident #162 was admitted to the facility in early September of 2024 with a past medical history that includes, but is not limited to, schizophrenia, epilepsy (brain disorder that causes seizures), and edema (swelling). The surveyor reviewed Resident #162's baseline care plan. The care plan designated that the Resident was his/her own representative. At the end of the baseline care plan there is a place for a written summary and a place for a signature where the care plan could be acknowledged as reviewed with the Resident or/or the Resident's Representative or Responsible Party (RP). No summary was written and no signatures were documented in either of the two designated signature lines. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interview with residents and staff, it was determined that the facility failed to answer call bells timely to attend to the needs of dependent residents. This was evident for 1 (Resident #19) on the Second Floor Nursing Unit. The findings include: During an interview conducted with Resident #19 on 9/10/2024 at 8:40AM, the Surveyor was informed that over the weekend the resident used the call bell to get assistance to the bathroom and it took a long time for the staff to answer the call bell and provide assistance. The resident continued, stating that he/she has to wait and wait for long periods of time for the staff to assist him/her with his/her needs. The resident communicated that it is hard to wait when you have to go. On 9/17/2024 at 11:21AM, a review of Resident #19's electronic medical record revealed that the resident has impairment on one side and was dependent on staff for toileting and transferring needs. On 9/17/2024 at 12:14PM, the Surveyor requested call light response…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, and interview, it was determined that the facility failed to offer to help formulate or obtain a Resident ' s Advanced Directive. This was found to be evident in 2 (Resident #54, & #162) of 16 Residents reviewed for Advanced Directives during an annual survey. The finding include: Advance directives are legal documents that provide instructions for medical care and only go into effect if you cannot communicate your own wishes. The two most common advance directives for health care are the living will and the durable power of attorney for health care. 1a) On 9/11/14 at 12:25 PM, the surveyor reviewed Resident #54 ' s medical record. The review revealed that Resident #54 was admitted to the facility in late August of 2024. On further review the surveyor noted that a social worker assessment was completed on 8/22/24. In the section labeled Advanced Directives no box was checked to indicate if the Resident had an advanced directive or if the Resident did not if he/she would like to formulate one. On 9/13/24 at 9:10 AM, the surveyor interviewed the Social Director…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interview, it was determined that the facility failed to inform the Resident ' s Responsible Party (RP) of the need to alter treatment. This was found evident of 1 (Resident #70) of 3 residents reviewed for notifications. The findings include: On [DATE] at 11:32 AM, the surveyor reviewed Resident #70's medical record. The review revealed that Resident #70 was admitted to the facility in early 2023 from another facility. On further review, an admission note written on [DATE] by Resident #70's Physician and the facility's Medical Director (MD) #3, wrote Resident #70 had a history of ischemic CerebroVascular Accident (CVA), (condition where blood flow to the brain is blocked) with left-sided hemiparesis (one sided paralysis), and wrote Patient requires total care and is unable to participate in any medical decision making. Resident #70's Responsible Party was identified in the profile page as Resident's granddaughter. The surveyor reviewed a progress note written on [DATE] by Licensed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of Facility Reported Incidents (FRIs) and interviews with staff, it was determined that the facility failed to maintain documentation that a FRI was thoroughly investigated. This was evident for 1 (Resident #12) out of 13 residents investigated for FRIs during the annual survey. The findings include: On 9/10/2024 at 1:35PM, during an interview conducted with Resident #12, the Surveyor was informed that the resident reported a missing credit card months ago. On 9/16/2024 at 1:30PM, the Surveyor reviewed the resident's Personal Property Policy, section Our Responsibilities #1.) We must investigate any damage to or loss of the resident's personal property. On 9/16/2024 at 1:45PM, the Surveyor reviewed the facility's investigative file for Resident #12. Inside the file was a 39-555F Initial Report Form submitted to the Office of Health Care Quality on 2/09/2024 at 1:50PM and a 39-556F Follow-up Investigation Report Form submitted to the Office of Health Care Quality 2/13/2024 at 11:00PM. The Surveyor asked the Director of Nursing (DON) #2 if that file contained the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, and interview with and staff, it was determined that the facility failed to accurately assess and complete a Significant Change in Status Minimum Data Set (MDS) assessment within 14 days of the resident's enrollment into a hospice program. This was evident for 1 (Resident #50) out of 1 resident investigated for hospice during the annual survey. The findings include: The MDS (Minimum Data Set) is a standardized, comprehensive assessment of a resident's functional, medical, psychosocial, and cognitive status to develop a plan of care based on the resident's individualized needs. A Significant Change in Status MDS is required when a resident enrolls in a hospice program. Hospice is specialized care that provides physical comfort and emotional, social, and spiritual support for people with an anticipated life expectancy of 6 months or less. The hospice team includes doctors, nurses, social workers, and health aides who provide care that focuses on symptom management and quality of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and staff interview, it was determined that the facility staff failed to code the resident's status accurately on the Minimum Data Set (MDS) assessment. This was found to be evident for 2 (#7, #41) out of 42 residents reviewed during the annual survey. The findings include: The MDS is a federally mandated assessment tool that helps nursing home staff members gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. 1a) During a MDS record review on 9/12/2024 at 08:34 AM, the surveyor noted that Resident #7's current Annual MDS dated [DATE], Section L0200 B. No natural teeth or tooth fragment(s) (edentulous) was answered No. However, Resident #7 was observed to be edentulous during screening. During an interview on 9/12/24 at 09:56 AM, the MDS Coordinator was asked if Resident # 7's coding was correct for Section L0200…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, and interviews, it was determined that the facility failed to include and review all initial healthcare information and goals in the baseline care plan. This was found evident of 1 (resident #49) of 3 residents reviewed for care planning. The finding include: On 9/10/24 at 8:24 AM, the surveyor conducted and interview with Resident #49. During the interview Resident #41 reported that he/she had not had a care plan meeting yet. On 9/12/21 at 7:01 AM, the surveyor reviewed Resident #49 ' s medical record. The record revealed that in early July of 2024 Resident #41 was admitted to the facility with a past medical history that included but not limited to, disorientation, protein-calorie malnutrition and diabetes. On further review the surveyor reviewed Resident #49 ' s admission assessment completed on 7/9/24. The assessment indicated that Resident #49 was alert and oriented to his/herself and not to place or time. The surveyor reviewed the baseline care plan completed by Social Worker Assistant Staff #36 on 7/10/24 and the Nurse Supervisor Staff #4 on 7/11/24.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, and interview with staff, it was determined that the facility failed to facilitate timely care plan meetings after a resident's quarterly assessment to allow the resident and resident representative to participate in the care planning process. This was evident for 1 (Resident #38) of 3 residents investigated for care planning during the annual survey. The findings include: Interdisciplinary team (IDT) is a team of medical professionals that provide specific patient centered care to the residents within a facility. The MDS (Minimum Data Set) is a standardized, comprehensive assessment of a resident's functional, medical, psychosocial, and cognitive status to develop a plan of care based on the resident's individualized needs. A care plan is used to summarize a person's health conditions, specific care needs, and current treatments and outlines what needs to be done to plan, assess, and manage care. Care plans are developed, reviewed, and/or revised by the IDT after the completion of a comprehensive MDS assessment (Admission, Annual, Quarterly, Significant…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview with resident and staff, it was determined that the facility failed to evaluate and provide documentation that activities occurred that meet the needs of each resident. This was evident for 2 (Resident #38 & #54) of 2 residents investigated for activities during the annual survey. The findings include: 1a) During a tour of the second-floor nursing unit on 9/10/2024 at 8:26AM, the Surveyor observed Resident #38 in bed, with the head of the bed raised, watching TV. In the resident's room, Surveyor noted a June activity calendar posted on the far-right wall and a July activity calendar posted on the wall across from the front of the bed. There was no daily activity sheet observed. The Surveyor asked the resident about daily activities the facility provided for the residents. Resident #38 was unable to tell the Surveyor about the activities at the facility. The MDS (Minimum Data Set) is a standardized, comprehensive assessment of a resident's functional, medical, psychosocial, and cognitive status to develop a plan of care based on the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Basedonrecordreview andinterview itwasdeterminedthatthefacilityfailedtohavephysicianorderswrittentoassurepropercareandtreatmentswereinplaceforfoleycare Thiswasfoundevidentin1 (Resident#41) of3 residentsreviewedforurinarycatheterandUrinaryTractInfection(UTI duringthesurvey Thefindinginclude On9/12/24 at10:16 AM thesurveyorreviewedResident#41' s medical record. The review revealed that Resident #41 was readmitted to the facility in of late August of 2024 after a hospital stay and had a past medical history, including but not limited to, sepsis (body's overreaction to an infection) due to Methicillin Resistant Staphylococcus Aureus (MRSA), urinary tract infections, and obstructive uropathy (obstruction of urinary tract). The surveyor next reviewed the admission assessment dated [DATE] for Resident #41. In the Urinary Management section the question is a foley (a tube that helps drain urine from the bladder) present is checked yes. It further describes the reason as obstructive uropathy. The surveyor noted that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interviews, it was determined that the facility failed to ensure that a resident received services to promote healing of a pressure ulcer. This was found evident in 1 (Resident #49) out of 5 residents reviewed for pressure ulcers. The finding include: On 9/10/24 at 8:29 AM, the surveyor observed Resident #49 in bed with his/her feet on the mattress without any protective boots on and the surveyor noted green protective boots placed on a wheelchair that was located next to Resident #49's bed. On 9/12/24 at 8:25 AM, again the surveyor observed Resident #49 in bed without protective boots on and noted the green boots were up on the top of Resident #49's closet. On 9/13/24 at 9:59 AM, the surveyor observed Resident #49 in bed with his/her heels on the bed and no protective boots on. On 9/13/24 at 10:22 AM, the surveyor interviewed Licensed Practical Nurse (LPN) #9. During the interview the surveyor asked LPN #9 if Resident #49 was supposed to have protective boots on while in bed. LPN # 9 confirmed that Resident #49 should have boots on while in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interview, it was determined that the facility failed to provide treatment for constipation and maintaining bowel continence. This was found evident of 1 (Resident #41) of 3 residents reviewed for bladder and bowel during the survey. The finding include: On 9/10/24 at 1:30 PM, the surveyor conducted an interview with Resident #41. During the interview the resident stated that he/she had been having some troubles with bowel regularity while at the facility. On 9/12/24 at 10:16 AM, the surveyor reviewed Resident #41's medical record. The review revealed that Resident #41 was readmitted to the facility in late August of 2024 after a hospital stay. The surveyor reviewed the admission assessment dated [DATE] for Resident #41. In the Bowel Management section, the question that asks for use of laxative to move bowels was checked, yes. The surveyor reviewed the TASK Bowel Movement (BM) documentation for Resident #41. No BMs were recorded on 9/1/24, 8/7/24, 9/8/24, 9/10/24, and 9/11/24 and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, and interviews, it was determined that the facility failed to provide education for application of a device after the knowledge deficit was identified. This was evident in 1 (Resident #70) of 1 resident reviewed for devices. The findings include: On 9/17/24 at 11:32 AM, the surveyor reviewed Resident #70's medical record. The review revealed that Resident #70 was admitted to the facility in early 2023 from another facility. On further review of MD #3's progress notes a note written on 7/28/23 summarizes the history of present illness for Resident #70. The summary stated that after Resident #70's fell from his/her bed and developed bruising, the resident was transferred to the emergency room for evaluation. An x-ray showed a mildly impacted humeral (upper arm bone) neck (top part of the bone) fracture with recommendations for sling and nonoperative management. It further stated a CAT Scan (CT) showed a left pectoral (chest) muscular hematoma (a collection of blood that pools outside the blood vessel). Resident #70 was found to be anemic (low red blood cells)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and review of pertinent facility documentation it was determined that the facility staff failed to obtain appropriate certification for a Nurse Aide in Training (NAIT) in the required time frame. This was determined to be evident for 3 (#24, #25, and #26) of 6 NAIT's reviewed for certification. The findings include: 1a & b) On [DATE] at 11:11 AM, the surveyor conducted a review of 5 random NAIT employee files revealed that NAIT #24 was hired on [DATE]. Although this was during the pandemic waiver period, NAIT #24 was required to obtain a Geriatric Nursing Assistant (GNA) licensure by the end of the waiver period which was [DATE]. When the current Human Resources (HR) Director determined that licensure had not occurred in the appropriate time period, NAIT #24 was reassigned to the Assisted Living side of the facility on [DATE] until Licensure was obtained on [DATE]. She is currently employed as a GNA in the facility. NAIT #25 was hired on [DATE], but did not obtain licensure by [DATE]. The date…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, and interview, it was determined that the facility failed to obtain radiology services in a timely manner. This was found evident in 1 (Resident #70) out of 1 resident reviewed for radiology services. The finding include: On 9/17/24 at 11:32 AM, the surveyor reviewed Resident #70's medical record. The review revealed that Resident #70 was admitted to the facility in early 2023 from another facility. The surveyor next reviewed a progress note written by Licensed Practical Nurse (LPN) #29 on 7/15/23. The note described that a staff Geriatric Nursing Assistant (GNA) was performing afternoon cares and while attempting to roll Resident #70 onto his/her side Resident #70's legs slid out of bed and Resident #70's upper torso remained in bed. The surveyor reviewed Resident #70's paper medical record. The review revealed that on 7/17/23 LPN #29 communicated with a provider the observation of a bruise on Resident #70 via eMedicall with a response from the provider for labs in the morning and clarification of the previous fall. The surveyor reviewed the next eMedicall…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews with staff, and record reviews, it was determined that the facility failed to store food, dishes and monitor temperatures in a manner that maintains professional standards of food service safety. This practice had the potential to affect all residents eating food prepared in the facility's kitchen. The findings include: During the initial kitchen tour on 9/10/24 at 07:22 AM, the surveyor observed bottles of Oregano, Italian Seasoning, and Old Bay in use on the counter that were not labeled when opened or when to discard. [NAME] #18 stated that she just opened the containers and had not dated the spices yet. Additionally, unlabeled cheese, a meat patty, a bag of meat, and an opened scrambled egg carton were identified with the Dietary Team Lead who stated that we label items as they are opened but we may have missed some. A dishwasher temperature log was found with missing entries and a stack of wet bowls were found on the storage shelf upright in a manner that did not allow for drainage. On 9/12/24 at 11:03 AM, the surveyor interviewed the Certified…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2a) Maryland Medical Orders for Life-Sustaining Treatment (MOLST) is a form which includes medical orders for emergency medical services or other medical personnel regarding CPR (cardiopulmonary resuscitation) and other life-sustaining treatment options. Do Not Intubate (DNI) is an order placed in a person's medical record by a doctor informs the medical staff that chest compressions and cardiac drugs may be used, but no breathing tube will be placed. On [DATE] at 12:22PM, during a review of Resident #38's current paper medical record, the Surveyor discovered an incomplete MOLST form. Page 1 of the MOLST form was completed, signed and dated with a code status of Do Not Intubate (DNI). Page 2 was incomplete and signed and dated. On [DATE] at 12:25PM, the Surveyor informed Second Floor Supervisor #33 that Resident #38's MOLST form was incomplete. The Second Floor Supervisor #33 was asked to provide the Surveyor with the completed MOLST form. On [DATE] at 12:55PM the Director of Nursing (DON)#2 informed the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, and interviews, it was determined that the facility failed to maintain practices to help prevent the transmission of infections. This was found evident on 3 random observations made on the survey. The findings include: 1a) On 9/12/24 at 8:28 AM, the surveyor observed that Resident #41's had a foley catheter (a tube that drains urine from the bladder to outside the body) and observed the catheter connected to a drainage bag that was laying on the ground. On 9/12/24 at 8:30 AM, the surveyor observed Resident # 41 puts on his/her call button. Geriatric Nursing Assistant (GNA) #8 answered the call and Licensed Practical Nurse (LPN) # 7 walked past the room stating she would be in shortly and would be changing the foley drainage bag. On 9/12/24 AM, LPN #7 walked into Resident #41's room. At this time the surveyor asked LPN #7 why the foley drainage bag was on the floor. LPN #7 stated that she was informed by the GNA that the clip was broken this morning. LPN #7 then changed the foley drainage…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and staff interviews it was determined that the facility staff failed to ensure that food was stored and prepared in a sanitary manner. This practice had the potential to affect all residents in the facility. Finding includes: The initial tour of the kitchen took place on 09/04/19 at 10:26 AM. During the tour, the surveyor was accompanied by the Registered Dietitian (RD) who verified all surveyor observations. On 09/04/19 at 10:43 AM, the following were observed during the tour of the kitchen in the clean dry dish area: a whole cooking pan, a half pan, a full 6-inch pan, two full 2-inch pans, and one 4-inch full pan that contained water and dried food throughout the interiors of each pan. The RD and dietary supervisor verified writer's concerns. The Administrator and the Director of Nursing were made aware of surveyor's findings during survey exit.

Based on medical record review, the facility failed to provide the hospital with a copy of the comprehensive care plan goals upon resident's transfer. This was evident for 2 out of 2 residents (#11 and #59) reviewed for hospitalization. The findings include: 1. Resident #11 was admitted to this facility on 2/4/17 with multiple diagnoses. On 8/13/19 Resident #11 was sent to the hospital for an acute medical condition. During the transfer process to the hospital all paperwork went with the resident except for the comprehensive care plan goals. There was a bed hold policy sent with the ambulance driver but there was no letter sent to the responsible party that included the bed hold policy or why the resident was sent to the hospital. The Administrator was made aware on 9/5/19 at 11: 04 AM. 2. A medical record review was done for Resident #59 on 09/06/19 8:40 AM. Resident #59 was admitted to this facility on 7/13/19. On 7/26/19 Resident #59 was transferred back to the hospital for follow-up related to a recent surgery. Review of the paperwork sent to the hospital with the resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review, the facility failed to notify Resident #11 or his/her responsible party in writing as to why the resident was transferred to the hospital. This was evident for 1 out of 2 residents reviewed for hospitalization. The findings include: Resident #11 was admitted to this facility on 2/4/17 with multiple diagnoses. On 8/13/19 Resident #11 was transferred to the hospital for an acute medical condition. During the transfer process to the hospital all paperwork went with the resident except for the comprehensive care plan goals. Additionally, there was no evidence a letter was sent to the responsible party that included the bed hold policy or why resident was sent to the hospital. Administrator was made aware on 9/5/19 at 11: 04 AM.

Based on medical record review, the facility failed to provide the resident or responsible party with a copy of the bed hold policy. This was evident for 1 out of 2 residents (#11) reviewed for hospitalization. The findings include: Resident #11 was admitted to this facility on 2/4/17. On 8/13/19 Resident #11 was sent to the hospital. Review of the transfer paperwork revealed there was no letter sent to the responsible party that included the bed hold policy. Resident #11 was not his/her own decision maker. The Administrator was made aware on 9/5/19 at 11: 04 AM.

Based on review of medical records and interview with facility staff, it was determined that the facility failed to ensure that residents who receive treatment for disruptive or inappropriate behaviors have documentation of the nature and extent of those behaviors when residents exhibit them. This was evident for 1 (Resident #62) of 2 residents reviewed for behaviors. The findings include: Resident #62's medical record was reviewed on 9/5/2019 at 10:36 AM. During the review, it was noted that the resident had a stay of fewer than 30 days at the end of November into mid December of 2018. The resident was admitted without any medical history or diagnoses of mental illness, intellectual disability, or cognitive impairment. The resident was noted to be able to make his/her own decisions. An order was found for Resident #62 dated 12/7/2018 that stated, Psychiatric team to evaluate and treat as indicated due to inappropriate verbal behaviors. A recommendation from the psychiatric nurse practitioner and dated 12/13/2018 was found that stated, Namenda 5mg by mouth every day for dementia…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.